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Nurses are trained to learn and apply patient assessment skills. These skills are the cornerstone of being a proficient nurse. The knowledge and techniques to develop these skills are learned in the first two years of nursing school and honed in clinical as the student nurse takes on greater patient load. The “Standards of Care” that are the basis of nursing including the following:
Standard 1. Evaluation
assessment that the nurse must use all of their senses. These are hearing, touch, sight, and therapeutic communication. The cephalocaudal method is most always used. In other words, the assessment of the patient from head to toe. The nurse must self aware to be able to conduct a thorough assessment. Data collection forms the basis for the next step in the standards of care that is diagnostic. A nurse must have all the necessary equipment, such as scales, tape measure, thermometer, sphygmomanometer, stethoscope and pen light. The setting is also very important to make an assessment. If a client is nervous or anxious, they may not be as willing to answer questions or ask a nurse to examine. Get quiet environment is not always possible, especially in an emergency. The nurse must be very observant and try to get as much relevant data as possible to develop a nursing diagnosis For example, when making the assessment of a customer who is complaining of severe abdominal pain, ask them what foods they ate last would give the nurse more relevant information and ask them how many brothers or sisters they have.
Standard II. Analysis
A nursing diagnosis is not diagnostic. A diagnosis was a medical condition “Diabetes”. In terms of nursing diagnosis would be, “changed Tissue Perfusion”, associated with reduced oxygenation of tissues as evidenced by a pulse oximetry 92%, secondary to a medical condition “emphysema”. A nursing diagnosis is a formal statement that relates to how customers react to real or perceived illness. In making analysis nurse tries to devise measures to help customers reduce and or share how they respond to real or perceived illness.
Standard III. Outcome Identification
In this process, nurses use assessment and analysis to set goals for the patient to achieve to achieve a greater level of ease. Such a goal may simply be that the patient comprehends now command to test their blood sugar, or perhaps a new mother gleans a sense of security now that it has been assigned in the correct method of breastfeeding. The nurse must plan targets the customer reach around customer capacity. For example, the goal that the client will walk normally after two days, the knee is unreasonable, in the sense that the knee client will not be completely healed. However, the aim is that the customer must be able to demonstrate the proper use of crutches, would be more realistic. This goal is also measurable, since the patient in the hospital and the nurse can teach and observe demonstrations again. The targets or results for the client must also be measurable.
Standard IV. Planning
The planning standard is designed around customer activities while in hospital. The nurse must plan to teach and perform tasks when the patient is free to learn. This would include giving painkillers before learning to walk with crutches or wait until after the patient has completed meal before teaching about how to use a syringe. The atmosphere should be conducive to the customer to learn.
Standard V. Implementation
This standard requires that the nurse put to the test methods and measures to help customers achieve their goals. In practice, the nurse performs the functions necessary to plan the customer. If teaching is one of the goals that the nurse would record the time, place, method and information taught.
Standard VI. Mat
Evaluation is the final standard. In this step the nurse makes a decision on whether or not the objectives originally set for the client have been met. If the nurse concludes that the objectives or goals are not met, the program has to be reviewed and documented as such. The goal should be timely and measurable. If the objectives of the client was using crutches successfully, and the customer was able to perform repeated presentation for the nurse, the goal was met.
The above standards are the cornerstone of the nursing profession. These standards take time and experience to learn and to implement. Experience is the best teacher, and nurse should constantly strive for excellence in the care of patients, and recognize how to help patients achieve greater physical and emotional well-being.
For more information on nursing education network Study Guide.
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Source by Nancy Kimmel